Assessment
This type of assessment is performed shortly after being admitted to a healthcare facility and establishes a baseline for the patient.
What is Initial Assessment
This term refers to a clinical judgment about a patient's response to an actual or potential health problem or life process.
What is Nursing Diagnosis
What term describes the specific, measurable, and time-bound statements that indicate the expected results of nursing interventions?
What is Goals and Planning, acronym SMART
What is the critical task in the implementation stage that ensures accurate recording of patient care activities and responses?
What is documentation
In the evaluation stage, what is the primary method used to record the patient's response to nursing interventions and the effectiveness of care?
What is documentation
This type of data is observable and measurable.
What is Objective Data
In the nursing diagnosis stage, what type of data is collected to help identify health problems or potential issues in a patient?
What is subjective and objective data
In nursing care planning, these types of goals are typically achieved within hours to a few days.
What is short term goals
In the implementation stage, what process involves continuously collecting data to monitor the patient's condition and response to care?
What is ongoing assessment.
In the evaluation stage, what crucial skill do nurses use to make clinical judgments about the patient's response to care and the need for adjustments?
What is nursing judgement
Tool used by healthcare practitioners to assess patient complexity using social determinants of
health.
Unlike problem-focused nursing diagnoses, these types of diagnoses focus on the patient's potential for enhanced well-being.
What is Health Promotion Nursing Diagnosis
Why is it important for nurses to tailor their care plans to each patient's unique needs and circumstances?
What is the foremost concern for nurses during the implementation of nursing care, ensuring that no harm comes to the patient?
What is safety?
If the evaluation reveals that the patient's condition has not improved as expected, what action should the nurse take in response to this information?
What is modification
What are 4 assessments that help us establish priorities for our patients?
What is Health orientation, developmental stage, culture, and need for nursing
Nursing diagnoses related to potential complications or issues that require interprofessional collaboration fall under this category.
What is a Collaborative Nursing Diagnosis
When developing nursing interventions in the planning stage, nurses should strive to incorporate the best available research and clinical expertise. What is this approach called?
What is Evidence-Based Practice
During implementation, what essential nursing role involves teaching patients about their health conditions, medications, or self-care?
What is patient education
What key activity in the evaluation stage involves collecting data to determine changes in the patient's condition since the implementation of nursing interventions?
What is reassessment
When do you verify your data?
When there is a discrepancy between what the person is saying and what the nurse is observing and when the data lacks objectivity
In the nursing diagnosis process, what technique involves organizing assessment data into groups or patterns to identify potential health problems?
What is Data Clustering
What step in the planning stage involves determining the most important nursing diagnoses and interventions based on the patient's needs and resources?
What is priority setting
In the implementation stage, what communication skill is essential for building trust and rapport with patients?
What is therapeutic communication
In the evaluation stage, what term is used to describe the process of determining whether the patient has met the expected outcomes?
What is Goal Met, or Goal Achieved?